Personal Injury Intake | The White Law Firm, P.C.

1

Personal Information

Your contact details and basic information

First Name *

Last Name *

Date of Birth *

Social Security Number

Street Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

Preferred Contact Method

Best Time to Reach You

2

Accident Details

Information about the incident

Date of Accident *

Time of Accident

Location of Accident *

Type of Accident *

Describe What Happened *

Weather Conditions

Were there any witnesses?

Yes No Not Sure

Was a police report filed?

Yes No Pending

Police Report Number (if available)

3

Injury Information

Details about your injuries from the accident

Please describe your injuries in detail

Current pain level (1-10)

Have you suffered any of the following as a result?

Lost Time from Work Disability Emotional Distress Sleep Issues Difficulty with Daily Activities

4

Medical Treatment

Information about your medical care

Did you receive medical treatment at the scene?

Yes No

Were you transported by ambulance?

Yes No

Did you go to the emergency room?

Yes No

Hospital/ER Name (if applicable)

Are you currently receiving medical treatment?

Yes No

Primary Care Physician/Doctor Name

Types of treatment received (Select all that apply)

X-Rays MRI CT Scan Surgery Physical Therapy Chiropractic Care Medication

Do you have any pre-existing conditions?

5

Insurance Information

Your insurance and the at-fault party's information

Your Auto Insurance Company

Policy Number

Claim Number (if filed)

Health Insurance Company

Health Insurance Policy Number

At-Fault Party Information

At-Fault Driver's Name (if known)

At-Fault Party's Insurance Company

Their Policy Number

Their Claim Number

6

Additional Information

Final details and submission

Vehicle Information (Year, Make, Model)

Was your vehicle towed?

Yes No N/A

Property Damage Description

Employment Information

Have you missed work due to this accident?

Yes No

If yes, how many days/weeks?

Have you spoken with any other attorney about this case?

Yes No

How did you hear about us?

Any additional information you'd like to share?

⚠️ Important Disclaimer

By submitting this form, you acknowledge that the information provided is accurate to the best of your knowledge. Submission of this form does not create an attorney-client relationship. Our team will review your information and contact you to discuss your case. All information is kept strictly confidential.

I acknowledge the above disclaimer and consent to be contacted regarding my case. *

The White Law Firm, P.C.

Personal Injury Intake Form

Personal Information

Accident Details

Injury Information

Medical Treatment

Insurance Information

At-Fault Party Information

Additional Information

⚠️ Important Disclaimer

Thank You!